Tobacco Use Reduction in PLWH Program: Tobacco …



Michigan Department of Health and Human Services Tobacco SectionTobacco Use Reduction in PLWH Program: Tobacco Treatment Specialist Standard Operating Procedures ManualContent TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc525207335 \h 2Tobacco Use Reduction in People Living with HIV: Contractor and MDHHS Tobacco Section Requirements PAGEREF _Toc525207336 \h 3Contractor Specific Requirements PAGEREF _Toc525207337 \h 3Department Requirements PAGEREF _Toc525207338 \h 5Tobacco Use Reduction in PLWH Coordinator & Contractor Overview of Responsibilities PAGEREF _Toc525207339 \h 6MDHHS Tobacco Section Consultant Role PAGEREF _Toc525207340 \h 7Tobacco Dependence Treatment Policies/Protocols Assessment Tool PAGEREF _Toc525207341 \h 8FY 19 CAREWare Data Entry PAGEREF _Toc525207342 \h 10CAREWare Service Definitions PAGEREF _Toc525207343 \h 10CAREWare Screenings PAGEREF _Toc525207344 \h 11CAREWare Reports PAGEREF _Toc525207345 \h 11Client Eligibility PAGEREF _Toc525207346 \h 12Consent and Confidentiality PAGEREF _Toc525207347 \h 13Incentives Policy PAGEREF _Toc525207348 \h 13Tobacco Treatment Transportation Services PAGEREF _Toc525207349 \h 15Tobacco Dependence Treatment Forms: Intake, Assessment, and Treatment Plan PAGEREF _Toc525207350 \h 15Best Practices and Guidelines for Successful Tobacco Dependence Treatment Programs PAGEREF _Toc525207351 \h 22Ten Key Guideline Recommendations PAGEREF _Toc525207352 \h 22Sample Tobacco Use Reduction Policies and Protocols PAGEREF _Toc525207353 \h 23Health Department Example: Ingham County Health Department PAGEREF _Toc525207354 \h 24Clinic/Health Care Setting Example: University of Michigan Health System (UMHS) HIV/AIDS Treatment Program (HATP) PAGEREF _Toc525207355 \h 27AIDS Service Organization Example: Wellness Services Inc. PAGEREF _Toc525207356 \h 29Carbon Monoxide Monitor Policy PAGEREF _Toc525207357 \h 31CO Monitor Policy Example: Mayo Clinic PAGEREF _Toc525207358 \h 31CAREWare Consent Form: Sample PAGEREF _Toc525207359 \h 33Resources PAGEREF _Toc525207360 \h 34IntroductionTobacco use remains the leading cause of preventable disease and death in the United States with almost 500,000 people dying annually from tobacco-related diseases (heart disease, cancer, stroke, COPD, and diabetes). People living with HIV (PLWH) who smoke cigarettes die an average of 12 years sooner from smoking-related disease compared to those who have not smoked (Helleberg, online Journal of Clinical Infectious Disease). In Michigan, 50% of People Living with HIV (PLWH) are tobacco users according to the 2015 HIV Tobacco Reduction Client Survey, Tobacco Section MDHHS. To reduce the smoking rate in PLWH, the MDHHS Tobacco Section and HIV Care and Prevention Section have collaborated to partner with AIDS Service Organizations, Local Health Departments, and Infectious Disease clinics to provide Tobacco Dependence Treatment services. Based on the 2017 HIV Tobacco Reduction Client Survey, there has been a great reduction in smoking prevalence to 41% compared to the 50% in the 2015 survey.This document outlines the Tobacco Use Reduction Program (TURP) for PLWH standard operating procedures for all MDHHS funded programs. The purpose of these standards is to ensure quality and consistency of MDHHS funded Tobacco Treatment Services throughout the state. These standards were developed in collaboration with Ryan White service providers, Tobacco Section, and HIV Care and Prevention Section. MDHHS Tobacco Section TURP activities are aligned with the Clinical Practice Guidelines for Treating Tobacco Use and Dependence (2008 update), Tobacco Treatment Specialist protocol, HRSA Ryan White guidelines, and MDHHS HIV Case Management Standards of Care. In reviewing the standards in this document, it is important to keep in mind the following:In addition to being adherent to these standards, it is important to be compliant to HIPAA security and privacy rules when handling confidential information Throughout the document, the term client refers to individuals being served by the TURP and can be used interchangeably with patient, consumer, or community member This is a living document and may change based on the MDHHS Tobacco Section, MDHHS HIV Care and Prevention Section, or the Treating Tobacco Use and Dependence Clinical Practice Guidelines. To offer comments regarding this document or considerations for future revisions, please contact MDHHS Tobacco Section at 517-335-8381Tobacco Use Reduction in People Living with HIV: Contractor and MDHHS Tobacco Section Requirements Contractor Specific RequirementsIf funding is available, implement annual work plan that describes the objectives, activities, and measures for work to be performed under this contract. The work plan will include measurable outcomes for services provided for each funded service.Ryan White is payer of last resort; as such, the Contractor must adhere to the Ryan White HIV/AIDS Treatment Extension Act. The Contractor must adhere to applicable federal and state laws, as well as policies and program standards issued by the Department. See “Applicable Laws, Rules, Regulations, Policies, Procedures, and Manuals.” The Department may update and/or add guidance within the contract year with written notice. The Department will supply any new additions to the organization/agency. The Contractor must adhere to:All Federal and Michigan laws pertaining to HIV/AIDS treatment, disability accommodations, non-discrimination, and confidentiality.Procedures for the confidentiality and security of client information.All Federal and state issued guidance(s) and policy(ies) for services provided.The Department will monitor Contractor performance throughout the contract year, which may include a review of financial status reports (FSRs), CAREWare data entries, quarterly progress reports, and site visits. For site visits:Monitoring may include a review of fiscal, program, administrative, quality management, and client health records to ensure compliance with Federal, Department, and contract requirements. The Department will provide 30 calendar days written notice of the site visit, including an agenda and the assessment tool to be used. The Department will provide a written report post-site visit, including a Performance Improvement Plan template, if warranted, within 45 calendar days. The Contractor must complete the PIP template and submit to the Department within 30 calendar days of receipt of the report.The Contractor will ensure that records are available for review by the Department auditors, staff and Federal government agencies, if applicable, to monitor performance. The Contractor will maintain and provide access to primary source documentation. The Contractor may enter into subcontracts or vendor agreements to fulfill the service delivery expectations of this agreement.The Contractor must assure that all subcontracts issued under this funding agreement are subject to the same requirements as outlined in this agreement and subject to prior approval by the Department before work has begun.The Contractor must monitor subcontractors annually to assess compliance with the subcontract; take primary responsibility to monitor follow-up and remediate in cases where the subcontracted entity is not in compliance with the contract; report the results of all contract monitoring activities to the Department.The Contractor must provide, upon request, a copy of all fully signed subcontracts, memorandums of understanding (MOUs) or letters of agreement related to the services in this agreement.The Contractor must provide immediate notification to the Department, in writing, in the event of any of the following:Any formal grievance initiated by a client and subsequent resolution of that grievance.Any event occurring, or notice received by the Contractor or subcontractor, that reasonably suggests that the Contractor or subcontractor may be the subject of, or a defendant in, legal action. This includes, but is not limited to, events or notices related to grievances by service recipients or Contractor or subcontractor employees.Any staff vacancies funded for this project that exceed 30 days.When issuing statements, press releases, requests for proposals, bid solicitations and other documents describing projects or programs funded in whole or in part with Federal money, the Contractor receiving Federal funds, including but not limited to State and local governments and recipients of Federal research grants, must clearly state:The percentage of the total costs of the program or project that will be financed with Federal money.The dollar amount of Federal funds for the project or program.Percentage and dollar amount of the total costs of the project or program that will be financed by non-governmental sources.The Contractor must participate in the Department needs assessment and planning activities, as requested.The Contractor must maintain, for a minimum of four years after the end of the budget period, program and fiscal records and files including documentation to support program activities and expenditures, under the terms of this agreement. Each employee funded in whole or in part with Federal funds must record time and effort spent on the project(s) funded. The Contractor must:Have policies and procedures to ensure time and effort reporting.Assure the staff member clearly identifies the percentage of time devoted to contract activities in accordance with the approved budget.Denote accurately the percent of effort to the project. The percent of effort may vary from month to month, and the effort recorded for Ryan White funds must match the percentage claimed on the Ryan White FSR for the same period.Submit a budget modification to the Department in instances where the percentage of effort of contract staff changes (FTE changes) during the contract period.The Contractor and its subcontractors are required to use the HRSA-supported software CAREWare to enter client and service data into the centrally managed database on a secure server. The Contractor must:Enter all Ryan White services delivered to HIV-infected and affected clients. Enter all data by the 15th of the following month. Complete collection of all required data variables and the clean-up of any missing data or service activities by the 15th of the following month.The Contractor will participate in regular Contractor meetings which may be face-to-face, teleconferences, webinars, etc. The Contractor is highly encouraged to participate in other training offerings and information-sharing opportunities provided by the Department.The Contractor must submit Workplan Progress Reports to the contract manager.Period CoveredReport Due DatesOctober 1, 2018 – December 31, 2018Tuesday, January 15th, 2019January 1, 2019 – March 31, 2019Monday, April 15th, 2019April 1, 2019 – June 30, 2019Monday, July 15th, 2019July 1, 2018 – September 29, 2019Tuesday, October 15th, 2019The Contractor must collaborate with the Tobacco Section staff to accomplish goals through, at the least, monthly calls, one annual site visit, and other grant monitoring tools and technical assistance activities.Performance will be measured on progress toward meeting the overall Tobacco Use Reduction in PLWH workplan objectives.Failure to comply with these requirements may result in punitive consequences such as denial of future funding or other consequences as appropriate.Department RequirementsThe Department will monitor Contractor performance throughout the contract year, which may include a review of Financial Status Reports (FSRs), CAREWare data entries, quarterly progress reports, and site visits. For site visits, the Department will:Include a review of fiscal, program, administrative, quality management, and client health records to ensure compliance with Federal, Department, and contract requirements Provide 30 calendar days written notice of the site visit, including an agenda and the assessment tool to be usedProvide a written report post-site visit, including a Performance Improvement Plan template, if warranted, within 45 calendar days Verify that the Contractor completed a response to the PIP template and submitted it to the Department within 30 calendar days of receipt of the reportMonitor Contractor’s completion of the PIP items and provide written documentation when all PIP items have been successfully fulfilledThe Department will review quarterly reports and provide written feedback within 30 calendar days of submission due dateTobacco Use Reduction in PLWH Coordinator & Contractor Overview of ResponsibilitiesIncrease individual and agency knowledge and awareness of the dangers of tobacco use in PLWH. Attend Tobacco Treatment Specialist (TTS) training, with at least one staff member as a certified Tobacco Treatment Specialist.Share project progress and data with agency staff and agency stakeholders.Collaborate with the LGBTQ agencies for Precontemplation Classes.Participate in bi monthly TURP technical assistance calls.Attend basic and advanced motivational interviewing (MI) training.Attend related webinars, trainings, and conferences.Out of state travel is allowable if there isn’t an in state equivalent training or conference. Out of state travel must be approved by consultant prior to registering and must be supported by approved contract budget. Participate and assist in distribution of TCP coordinated client and staff surveys. Assist PLWH in Care with quitting tobacco use.Develop and implement an agency wide policy and process for implementing the 5A’s in routine client interactions. Provide tobacco treatment counseling to clients or refer to the Michigan Tobacco Quitline. Become familiar with FDA approved tobacco cessation medication, counsel, refer for prescription, and monitor medication adherence for clients as necessary. Utilize various tools acquired from workplan specific trainings when providing tobacco treatment counseling to clients.Create and distribute client tobacco resource materials. Comply with MDHHS TURP workplan and contract plete all objectives listed on the workplan for the appropriate fiscal year. Submit completed workplan reports and attachments to assigned MDHHS consultant. Document use of Tobacco Dependence Treatment in CAREWare and on workplan progress reports.Ensure all financial status reports are submitted to EGrAMS on a timely basis. EGrAMS training and links are included in resources appendix. MDHHS Tobacco Section Consultant RoleSupports contractors in achieving goals and objectives in their communities.Provides technical assistance and resources to contractors and others.Conducts new project coordinator/contractor orientation.Provides tobacco related materials. Online resourcesSample mediaWorkplan toolkitsState and local resources, reports and dataPolicy languageTrainingTobacco or HIV related informationTobacco project coordinator skillsDocumenting Tobacco Dependence Treatment services in CAREWareSupports tobacco related activities.Attends Tobacco Section meetings and communicates updates to contractors.May organize regional network meetings and project related conference calls.Attends local tobacco reduction coalition meetings and provides state updates.Provides updates/shares tobacco related information within MDHHS and to partners and key stakeholders.Attends Tobacco Section webinars.Acts as speaker at various professional meetings and internal department meetings.Program BudgetEnsures agency stays on track with FY budget.Educates on how tobacco use disparately affects certain populations and provides general education on disparities.Monitors progress on workplan activities and program spending through periodic site visits (in person and/or by phone) during the FY.Approves Contractor Workplans, Contracts, and Financial Status Reports using EGrAMS system. Provides feedback on workplan progress reports within 30 days of submissionCommunicates Tobacco Section goals to contractors and facilitates discussions on successes and problem solving amongst anizes calls and meetings to address challenges. Tobacco Dependence Treatment Policies/Protocols Assessment ToolCheck off items below that are included in your organization’s existing policies and protocols for tobacco dependence treatment. Identify and assign staff to implement each component of the Clinical Guidelines for Treating Tobacco Use and Dependence. Include tobacco dependence interventions in job descriptions and in the performance evaluations of staff. Staff training to provide the interventions, in the process, 5A’s and motivational interviewing. Monthly, quarterly, or annual goals pertaining to clinical tobacco treatment performance are identified and clearly communicated to all staff involved in tobacco dependence treatment. Every patient is asked about any and all current and past tobacco use, including electronic nicotine delivery devices, at every visit. All pregnant women are asked about tobacco-use status using the multiple-choice format recommended by the Clinical Guidelines for Treating Tobacco Use and Dependence. (Pages 165-173) Record tobacco use status (current, former, never) in a designated place, such as a sticker or stamp, on all patient charts or indicate smoking status using computer reminder systems. CAREWare and/or Electronic Medical Record includes tobacco use screening questions and has capability to be adapted in order to guide the tobacco dependence treatment. Once a tobacco user is identified, a trigger is in place to alert the Health Care provider to address tobacco use and treatment. Health Care Professional strongly advises every patient who uses tobacco to quit. Once a tobacco user is identified and advised to quit, the clinician assesses the patient’s willingness to quit at this time. Designated clinical staff are assigned to talk to patients about evidence-based treatment options, such as Nicotine Replacement Therapy and the Michigan Tobacco QuitLine. Health Care Professionals and/or Providers are trained on the appropriate uses, contraindications and prescribing issues associated with Nicotine Replacement Therapy and FDA medication options. Referrals are made to evidence-based tobacco dependence treatment resources. Designated staff follow-up with patients at a determined interval to assess patients’ progress with quit attempt and provide further resources as necessary.Other items of note in your current policies/procedures/protocols:__________________________________________________________________________________________________________________________Source: Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.Online link: 19 CAREWare Data Entry Along with tobacco dependence treatment (TDT) services, tobacco staff must use CAREWare to document Ryan White eligibility and client demographics. All staff providing data entry must sign a user agreement, and all clients receiving TDT services must give consent to be enrolled in CAREWare. Example consent form is provided in the Sample Policies section.CAREWare reports will be used for documentation of performance measures outlined in the workplan. Please reference the CAREWare Guide for specific instructions on how to input the required data. Below is a list of sub-service categories and definitions. 1 subservice unit=15 minutes (if subservice was less than 15 minutes still use 1 unit. You cannot record half units in CAREWare)CAREWare Service DefinitionsAsk- Routinely screening for tobacco use.Advise- In a clear, strong, and personalized manner, urge the client to quit.Assess- Briefly assess client’s readiness to quit.Assist: Individual TDT Counseling- Referred to one on one tobacco dependence treatment counseling provided by either the Contractor TTS or referred out to another TTS. Assist: TDT Group Counseling- Referred to a group session dedicated to addressing tobacco dependence treatment. Assist: TDT Educational Class- Referred to a group session or class that focuses on a wide variety of tobacco and/or health topics. Assist: Thinking About Quitting Class- Referred to a Precontemplation class hosted by a local participating LGBT Agency. Assist: Referred to Provider for TDT Medication- Referred to provider to prescribe client TDT medication.Assist: TDT Medication- Provider prescribed TDT medication to client. Assist: Michigan Tobacco QuitLine- Referred to QuitLine either verbal or through the fax referral process. Assist TDT Transportation: Client received transportation assistance to access TDT services.Assist TDT Gift Card: Client received a gift card incentive for completing an allowable TDT intervention.Arrange- Follow up appointments (call or in person).Successful Quit Attempt- Defined as no tobacco product use for 1 day or longer (Behavioral Risk Factor Surveillance System definition of quit attempt).Quit Attempt Relapse- Client has returned to former behavior or has prolonged use of tobacco products after quitting for 1 day or longer. Quit Attempt Slip- Client has brief return to tobacco use after quitting for 1 day or longer.Quit Attempt Not Initiated- Client did not attempt to quit tobacco products. CI (Completed Intervention): Individual TDT Counseling- one on one tobacco dependence treatment counseling provided by TTS at the agency.CI: TDT Support Group-Client attended a group session dedicated to addressing tobacco dependence treatment. CI: Michigan Tobacco QuitLine- Client called the QuitLine or answered when Quit Coach contacted them.CI: TDT Educational Class- Client attended class or group session that focuses on a wide variety of tobacco and/or health topicsCI: Thinking about Quitting Class- Client attended precontemplation classes offered through a local participating LGBT Agency.CI: Medication- TDT medications, either over the counter or prescribed, that the client received.Intake-TTS obtains consent for CAREWare, collects Ryan White Eligibility and demographic data, and conduct assessment of client quit history, medical history, motivation for quitting, etc.Tobacco Treatment Plan-TTS works collaboratively with client to develop a treatment plan that addresses triggers, barriers to quitting, and relapse prevention. Tobacco Dependence Treatment Discharge-Client no longer receives TDT services. CAREWare ScreeningsTobacco Use Type-indicate the type of tobacco products the client uses. If there are more than one, use the notes section to add the other products. Tobacco Use Length-indicate how long the client has been a tobacco user.Tobacco Use Decreasing- indicate when a client is still a tobacco user but is tapering down the amount of tobacco products as they move toward complete cessation. CAREWare ReportsData entry in CAREWare is vital to the sustainability of the TURP project; therefore, Contractors must submit CAREWare reports along with the workplan progress reports. The following are the required reports in CAREWare:Performance Measure Reports: The performance measure reports have a numerator (clients who satisfy the measure) and denominator (clients who are eligible for the service that is being reported). The TDT services that are performance measures are: 1TDT Tobacco Ask, 1 TDTAD Tobacco Advise, 1 TDTAS Tobacco Asses. Contractors must indicate the “As of Date” for the last day in the reporting period.Custom Reports: The custom reports are created to account for screening the length of tobacco use and the type of tobacco product. TTS can also track if a client is decreasing their tobacco use. The custom report for the TURP program workplan progress reporting is Tobacco Use Ask. Contractors must indicate the date range for the reporting period.Financial Reports: The financial report provides an overview of all service categories and subservices that were provided and specifies how many clients were served. Contractors will submit the Financial report for their specific agency and indicate the date range for the reporting period.Client EligibilityClients are eligible to receive Tobacco Dependence Treatment from a TURP Contractor if they are an active tobacco user living with HIV and meet the criteria for MDHHS-funded Ryan White services (MDHHS Ryan White Guidance #14-01). An individual is eligible for MDHHS Ryan White funded services if they meet the following criteria:Must be HIV positiveMust reside in MichiganMust be low income (not to exceed 500% of Federal Poverty Level)Must be underinsured or uninsured for applicable Ryan White services that are reimbursable through third party payers. All participants must provide verification of their HIV status, residence, insurance, and income upon enrollment. The following acceptable documentation for verification of status are:Laboratory documentation: Type differentiation (e.g. Geenius), Western Blot, viral load, viral culture, genotype, Nucleic Acid Amplification Test (NAAT), or 2 Dual immunoassay (IA) results positive for HIV (assays must be from different manufacturers)Documentation from licensed physician or their designee, as allowed under Michigan law verifying the individual’s HIV status. The following acceptable documentation for verification of residence are:Current State ID or Driver licensePassport with Michigan addressUtility bill in individual’s name showing addressBenefit awards letter from Department of Human Services (DHS) or Social Security Administration (SSA) with individual’s name and addressVoter registrationLease or mortgage in individual’s name showing addressCurrent Michigan Drug Assistance Program enrollment documentationDeclaration for Residence/No Income or Support/Insurance Ineligibility (MDHHS-5422 form)The following acceptable documentation for verification of income are:Benefit award letter (MDHHS/SSA)Most recent pay stubsTax forms from previous yearUnemployment benefit awardDepartment of Corrections release papers within 30 days of releaseEmployment Verification Form (MDHHS-5644)Declaration of No Income or Support (MDHHS 5422)The following acceptable documentation for verification of insurance are:Insurance cardsDenials from DHS/SSAAffordable Care Act Marketplace Eligibility Determination LetterCurrent Michigan Drug Assistance Program enrollment documentationDeclaration of Insurance Ineligibility (MDHHS-5422)All clients must be in care as defined by the HRSA core performance measures as having one of the following:2 medical visits every six monthsOr one in the first six months of the measurement year and one visit in the second six months of the measurement yearMedical visit is measured by:Viral load labCD4 LabServices in CAREWareEIS Linkage to Medical Care ConfirmedMedical Case Management HIV Specialist ConfirmedAny Subservice for Outpatient Ambulatory Medical CareConsent and ConfidentialityTobacco Treatment Specialist must receive consent to enter basic client information into CAREWare during intake. This can be verbal or written consent. Clients must be informed the following:Client’s date of diagnosis, transmission risk factors, medications, mental health and/or substance use diagnosis, service utilization, and demographic information will be entered into CAREWare (name, date of birth, race, ethnicity, gender, address, and phone number)This information is collected for generating reports, avoiding duplication of services, and coordination of care for people living with HIVSecurity precautions will be maintained to prevent unauthorized access to CAREWare by anyone other than program staff and other Ryan White ContractorsAny information that clients provide for the purpose of receiving services will not be disclosed without a client’s expressed written or verbal consent, unless it is required by law or if necessary to prevent a serious attempt to inflict harm on the client or others. Sample consent and confidentiality forms are provided in the Sample Policies section.Incentives PolicyTURP allows Contractors to purchase incentives for clients receiving Tobacco Dependence Treatment. A maximum of 5% of the overall budget can be allocated to incentives. Incentives are defined as quit kits, gift cards, and food.Gift Cards:Gift cards may not be redeemed for cash: VISA and MasterCard prepaid cards are not allowedGift cards may not be used for unallowable items, including but not limited to, purchase of alcohol, tobacco, illegal drugs or other substances, or firearms. They also may not be used to purchase tickets to entertainment, recreational or sports events, or clothing. For further explanation see HRSA Policy Notice 10-02Clients who receive gift card incentives must sign a statement acknowledging and agreeing to the purposes of and restrictions (i.e., unallowable costs) of the incentive. Contractor must maintain appropriate documentation for each participant gift card. At a minimum, this includes: List of each gift card by number with name of client who received the card with that number, the value of the card, the date the card was provided to the participant, and the purpose for which the participant received the incentive. Copy of the participants signed acknowledgement/agreement. Record of the number of incentives and cumulative total amount received by each participant during each contract year. Gift cards cannot exceed $10 and should be redeemed at retailers that do not sell tobacco e.g. CVS, Target, and Kroger when possible. The maximum annual limit for how many gift cards a client can receive is $600.Allowable distribution of gift cards is for the following:Participating in precontemplation groups, support groups, workshops, stress management and healthy lifestyle seminarsAfter quit attempt (more than 24hrs without tobacco use)14 days after quit date30 days after quit date90 days after quit dateCompleting at least 4 calls with Michigan Tobacco QuitLineIndividual Counseling sessions for high acuity clients to reduce barriers to accessing treatment and increase quit attempts (TTS must document and client acuity level and justification for distributing gift card for individual counseling session)Quit KitsQuit kits are only distributed after initial intake and/or assessment.Contractor must maintain appropriate documentation for each participant quit kit. At a minimum, this includes:List of each quit kit distributed with name of client who received the quit kit, value of the quit kit, date it was distributed, and the purpose for which the client received the incentive Contractor must maintain documentation of receipts or invoices for quit kit items purchased.FoodFood can be provided for clients participating in Tobacco Dependence Treatment counseling groups, precontemplation groups, education groups, and healthy living seminars.Contractor must maintain documentation of receipts or invoices for food purchasedFood purchase must not exceed $5 per personFood may not be purchased for an individual client or pantry Contractor is advised to submit a list of participants who registered and/or attended the event or group. Tobacco Treatment Transportation ServicesTransportation services are to be used to reduce barriers to accessing Tobacco Dependence Treatment and provide support for clients participating in Tobacco Dependence Treatment counseling, groups, or referrals. Contractor must maintain documentation of receipts or invoices for transportation services.Transportation assistance will be offered as a last resort if other transportation options are not available. Transportation can be provided by:Gas card- amount of gas card will reflect the distance traveled round trip and does not exceed the federal reimbursement rate. Contractor must document mileage for distance traveled. Bus tokens or voucher- cash cannot be given for public transportation and Contractor must track distribution of the vouchers or tokens which includes the value of the bus token/voucher and reason for distribution.Cab/taxi- Contractors may establish a contract or agreement with a local provider of transportation services that maintains client confidentiality.Staff transportation- staff may transport clients if insurance and other liability issues are addressed. Tobacco Dependence Treatment Forms: Intake, Assessment, and Treatment PlanThe Tobacco Use Reduction Project for PLWH Intake form captures the necessary demographic and Ryan White eligibility information to open a client in the CAREWare tobacco domain. The 5 A’s assessment form gathers medical history, quit history, and smoking environment information so that the TTS can provide the most appropriate treatment resources. The Tobacco Dependence Treatment Plan must be an individualized treatment plan that reflects topics discussed in the assessment, include specific action steps, and should be updated periodically to ensure effective monitoring and support for clients during the quit process. Contractors must document the aforementioned information systematically and update as needed. Contractors are encouraged to use other Nicotine dependence or Substance use screening tools to provide additional information that may be needed for referrals and to support a successful quit attempt. Tobacco Use Reduction Project for PLWH Intake and AssessmentLegal first name: _________________________________Middle: ___________________Legal last name: __________________________________Preferred name: ________________Date of birth: _____/_____/_________SSN: ____________________Medical Insurance: _______________________ Income: ________________________________Address: __________________________________________________________________________Phone Number: ___________________________ Is it okay to leave a message? Yes No Sex at birth: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX IntersexedGender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Transgender Woman FORMCHECKBOX Transgender ManHIV status: FORMCHECKBOX HIV-positive, not AIDSDate of HIV diagnosis: _____/_____/_________ FORMCHECKBOX HIV-positive, AIDS status unknown FORMCHECKBOX CDC-defined AIDS Date of AIDS diagnosis: _____/_____/_________Transmission category: (check all that apply) FORMCHECKBOX Male who has Sex with Male(s) FORMCHECKBOX Heterosexual contact FORMCHECKBOX Blood Transfusion FORMCHECKBOX Injecting Drug Use FORMCHECKBOX Perinatal Transmission FORMCHECKBOX Other: _________ FORMCHECKBOX Hemophilia/Coagulation Disorder FORMCHECKBOX Undetermined/UnknownEthnicity: (choose one)Race: (check all that apply) FORMCHECKBOX Non-Hispanic FORMCHECKBOX White FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX Hispanic FORMCHECKBOX Other FORMCHECKBOX Black or African-American FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Arab/Chaldean5 A’s Pilot AssessmentASK- Systematically identify all tobacco users at every visit. For current smokers: “Tell me about your tobacco use”Smoking status: (check one) Current Smoker How long have they smoked? When did they start smoking? ______________ Ex- Smoker Encourage continued abstinence. Ask if any further help is needed at this time Cigarettes: Average number of cigarettes/small cigars smoked per day? __________________How soon after waking do you smoke your 1st cigarette? _______________________3276600154940What brand of cigarettes do you smoke? _________________ Other Tobacco Use: (Snuff, cigars, chew, pipe, e-cigs, vape, etc.) _________________________ADVISE-Urge all tobacco users to quit: “Most people already know that smoking is harmful. For you, some of the health benefits of quitting will be…. What are your concerns about continuing to smoke?” ASSESS-Medical History, Smoking Environment, Quitting History, Substance and Alcohol use, and determine motivation, confidence and readiness to make a quit attempt. Medical History: Have you ever been told by a doctor that you had any of the following conditions?Heart attack or anginaYes No Don’t Know Stroke Yes No Don’t KnowHigh blood pressure Yes No Don’t KnowDiabetes Yes No Don’t KnowEmphysema/Chronic bronchitis Yes No Don’t KnowAsthma Yes No Don’t KnowSeizure Yes No Don’t KnowEating disorder Yes No Don’t KnowSkin allergies or sensitivities Yes No Don’t KnowDepression Yes No Don’t KnowAnxiety Yes No Don’t KnowMedications: Please list all medications that you currently take (attach additional pages as needed).__________________________________________________________________________________________________________________________________________________________________________Smoking Environment: How many persons other than you live in your household? ___________ How many persons in your household smoke, other than yourself? _______Is your spouse a smoker? __________Among your close friends, what percentage would you say smoke?Almost none About 25%About 50% About 75%About 100%Among your co-workers, what percentage would you say smoke?Almost noneAbout 25%About 50%About 75%About 100%Doesn’t workQuitting History: How many times in your life have you tried to quit and not smoked for at least 24 hours ________When was your last quit attempt?Never tried to quitWithin the last monthWithin the last yearOver 1 year ago Over 5 years agoWhy did you quit that time? ______________________________________________________________How long did you go without smoking that time? Less than 1 day1 Day to 1 weekLess than 2 weeks but more than 1Less than 1 month but over 2 weeks Less than 3 months but over 1 monthLess than 1 year but over 3 months Over 1 yearWhy did you start smoking again? _________________________________________________________What is the longest time during which you quit and didn’t smoke any cigarettes (excluding hospitalizations)?Never or less than 1 day1 day to 1 week1 week to 1 month1 month to 3 months3 months to 12 months Over 1 yearDid you use any of the following to help you quit?Nicotine Gum or lozenge Yes NoNicotine Patch Yes NoNicotrol inhaler Yes NoZyban or Wellbutrin (Bupropion) Yes NoChantix (Varenicline) Yes NoOther medication Yes NoSupport Groups Yes NoOne on One counseling Yes NoTelephone counseling (QuitLine) Yes NoSubstance and Alcohol Use:How much of the following do you drink per day?Coffee _______Tea________Soft drinks (pop)_______ Decaffeinated drinks_______Do you ever drink alcohol? YesNoIf yes, how often?Daily3 or 4 times per week1or 2 time per week 1 or 2 times per month Less than once per monthDrink of choice: BeerWineHard liquorHave you ever felt dependent or had a problem with alcohol? YesNoDo you use any of the following substances?MarijuanaYesNoFrequency per week __________________Cocaine YesNoFrequency per week__________________HeroinYesNoFrequency per week__________________OtherYesNoFrequency per week__________________Motivation and Confidence in Quitting: “On a scale of 1 to 10…”How important is it for you to quit?Not at all 1 2 3 4 5 6 7 8 9 10 VeryHow confident are you that you could succeed at quitting? Not at all 1 2 3 4 5 6 7 8 9 10 Very If you were to quit today, what would be some reasons? _____________________________________________________________________________________Stage of Change: “What are your thoughts about quitting at this time?” Pre-contemplation (not considering quitting) Action (off tobacco 1 day to 6 months)Contemplation (thinking about quitting) Maintenance (off tobacco 6 months or more)Preparation (ready to quit in next 30 days)If in preparation ask: What steps have you taken to prepare for your quit attempt?_____________________________________________________________________________________ASSIST- For those interested in quitting “Can we discuss how you might go about quitting?”Discuss potential quit date: ____________________________________________________________How I feel when I try not to smoke or cannot smoke:□ Anger□ Desire□ Hunger□ Nervousness□ Anxiety□ Difficulty concentrating□ Impatience□ Restlessness□ Constipation□ Difficulty sleeping□ Increased eating□ Shakiness□ Craving□ Fatigue□ Irritability□ Other: □ Depression□ Frustration□ NauseaWhen do you smoke?□ Talking on the phone□ Celebrating□ Feeling sad□ Driving□ Finishing a job□ Feeling nervous□ Seeing a cigarette□ Having a family argument□ Feeling stressed□ Drinking coffee, tea, or pop (soda)□ Feeling lonely□ Feeling bored□ Drinking alcohol□ Feeling scared□ After eating□ Feeling angryWhich of the following stressors, if any, are you dealing with now? (Check all that apply)□ The death of someone close to you□ Geographical move□ Loss of an important relationship□ Important legal problem□ Divorce or separation□ Other:□ Major health problem□ New job□ None of the aboveIdentify additional triggers, coping strategies, and barriers to quitting: __________________________________________________________________________________________________________________________________________________________________________Recommend use of medication; encourage client to speak with PCP or ID about appropriate medicationARRANGE-Refer to other support servicesOffer referral to Michigan QuitLine: Client accepted referral: □ Yes□No TTS did fax referral______________Offer referral to healthy living seminars and groupsOffer referral to LGBT Pre-contemplation groupsDate for follow up TTS appointment_____________________________________________________TTS Signature_____________________________________________ Date: _____________Tobacco Dependence Treatment PlanTobacco Dependence Treatment PlanBest Practices and Guidelines for Successful Tobacco Dependence Treatment ProgramsThe Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update outlines Ten Key Guideline Recommendations. The goal of these recommendations is to strongly recommend the use of effective, evidence based tobacco dependence counseling and medications. Ten Key Guideline RecommendationsTobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long term abstinence. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline. Individual, group, and telephone counseling are effective and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:Practical counseling (problem solving/skills training)Social support delivered as part of treatmentNumerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempt to quit smoking -except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e. pregnant woman, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:Bupropion SR Nicotine gumNicotine inhalerNicotine lozengeNicotine nasal sprayNicotine patchVareniclineClinicians also should consider the use of certain combinations of medications identified as effective in this GuidelineCounseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. Telephone QuitLine counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quit lines and promote QuitLine use. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits. Sample Tobacco Use Reduction Policies and Protocols The success of a Tobacco Use Reduction Program is dependent upon the internal policies of the Contractor. Effective tobacco interventions require coordinated interventions that include all staff that interact with clients. The Tobacco Coordinator should ensure that agency staff have training and support to deliver consistent and effective interventions to tobacco users. Tobacco Coordinator and TTS must draft and implement a Tobacco Use Reduction Policy and have a clear process for identifying PLWH who use tobacco, referring those clients to TDT treatment, and accessing medications and support groups. It is also highly encouraged for the Tobacco Use Reduction Policies to include a smoke free campus policy to demonstrate institutional support for reducing the effect of tobacco on public health. Health Department Example: Ingham County Health DepartmentBACKGROUNDTobacco use is the principal cause of preventable deaths and negatively impacts the health of all users. Ingham County Health Department will follow the Michigan Quality Improvement Consortium (MQIC) Tobacco Control Guidelines and Public Health Service Tobacco Use and Dependence Clinical Practice Guidelines for all tobacco dependence treatment interventions. Deviation from these guidelines will occur only if mandated by the Medical Director or designee, in writing. PURPOSEThe Tobacco Dependence Treatment Standing Orders direct the protocol for the ICHD Tobacco Treatment Specialist. The goal is to provide effective treatment and intervention to members of the community with tobacco dependence disorder through research-based standards of practice for tobacco dependence treatment. IDENTIFIED POPULATIONSThe following identified tobacco users are a priority for this program:All Clients: Clients identified as using tobacco will be served. This includes any number of cigarettes smoked per day, insurance status or type of tobacco (spit, cigarettes, hookah, or electronic smoking device).All Community Members: community members with a primary care provider (PCP) outside of the ICHD system will be supported to develop a Quit-Tobacco Plan. The Form: Attachment A: Quit Tobacco Service: Request for Patient Support will be sent to the PCP. Based on the Referral, Tobacco Dependence Treatment will begin and be billed to the medical insurance. Client progress will be communicated to the PCP.Clients without medical insurance: anyone in Ingham County may access Tobacco Treatment Services through direct referral or self-referral. Counseling will be provided free of charge for those without medical insurance and may also be served by the Michigan Quit-Tobacco Line.Pregnant Women: Pregnant women may access Tobacco Treatment Services and will be supported to utilize Nicotine Replacement Therapy from their PCP or medical provider if prescribed by a provider. Tobacco Counseling will be available to all.Patients in Recovery: Patients new to addiction recovery double their chances of staying committed to recovery by quitting tobacco. All patients in recovery are encouraged to access quit-tobacco support as soon as possible. Patients with a Mental Health Diagnosis: Tobacco use makes psychotropic medications less effective and increases complaints of medication side-effects. Attachment B: “Drug Interactions with Tobacco Smoke.” Patients wishing to quit-tobacco will be supported with active communication to their PCP and Psychiatrist.Adolescent Smokers: The average age of first tobacco use in Ingham County is age 10 with regular tobacco use occurring by age 14. Adolescent Smokers under age 18 may receive quit-tobacco counseling.Patients not ready to quit: Advise the patient to quit. Relate current visit to smoking/tobacco use if relevant. Discuss Risks, Rewards and Roadblocks. Repeat the assessment at every visit. Resistant patients can be schedule for Tobacco Treatment Services to review how help is available for when the patient is ready. ASSESSMENT AND MANAGEMENTIdentify patient in NextGen in the Tobacco Cessation Template.Follow Attachment C: “Tobacco Treatment Specialist Documentation Guide;”Assessment in NextGen Tobacco Cessation Template identifies details of the current Smoking History and includes Health Screening Questions, Cessation History, Carbon Monoxide (CO) Reading and Passive Smoke Exposure;Patient Quit-Plan: Create plan at each visit, print for the patient and save in NextGen Patient Visit Record. Plan Includes: Techniques to Quit, Medication Options, Treatment Goals and Follow Up.Coding: Patients with an Assessment and Diagnosis Description of Tobacco Use Disorder will be coded using Diagnosis Description Code Z72.0.Medication Treatment: A Patient Plan that identifies a Medication Treatment will have the Quit-Tobacco Plan and Referral Form: Attachment A: sent to the Patient PCP for review and action. Billing: Duration of Counseling will determine the CPT code that is sent to billing when “Submit to Superbill” is selected.PCP Contact: PCP will be provided with Patient Quit-Plan, Referral and Patient Quit Plan from the final patient visit.Final Documentation: Tobacco Cessation will generate the visits Master document that is signed by the Tobacco Treatment Specialist and confirms the Patient Plan and Billing.MONITOR, DOCUMENT, AND FOLLOW-UPMonitor:Patient progress;Communicate to PCP any reported medication side effects; and Record CO reading at each patient visit.Document:Record patient visit in NextGen;Tobacco Treatment Specialist sign-off for counseling; andTobacco Treatment Specialist sign-off for billing. Follow-up: Enter notes in Method of Counseling for communication to ICHC providers;Encourage patient on becoming a former smoker; andInvite patient to utilize up to seven visits per year.REFERENCESReferences Accessed September 2016:Tobacco Control Guidelines: Michigan Quality Improvement Consortium, Clinical Practice Guideline Update Alert: Treating Tobacco. Accessed September 14, 2016: Tobacco Use and Dependence, Clinical Practice Guidelines: 2008 Update, Public Health Services. Accessed September 14, 2015: A: Quit Tobacco Service: Request for Patient SupportAttachment B: Drug Interactions with Tobacco SmokeAttachment C: NextGen Tobacco Treatment Specialist Documentation GuideClinic/Health Care Setting Example: University of Michigan Health System (UMHS) HIV/AIDS Treatment Program (HATP)Tobacco Cessation Policy & ProceduresPURPOSE:To provide a standardized way to assess patient’s tobacco use, readiness for quitting, referrals to assistance, Nicotine Replacement and prescriptions, and follow-up. GUIDELINES:The University of Michigan Health System is committed to reducing the use of tobacco among our HIV-positive patient population.All patients of the HATP should be screened for tobacco use at every visit.Patients who use tobacco should be advised to quit tobacco use at every visit.The “Five A’s” (ASK, ADVISE, ASSESS, ASSIST, ARRANGE) should be used to assess tobacco use, readiness to quit, referrals, and follow-up procedures.All members of HATP staff should be involved with the tobacco cessation program.PROCEDURES:Upon intake for every patient at every appointment, their tobacco use will be assessed (ASKED) by the Medical Assistant (MA) or Registered Nurse (RN) who is rooming the patient, prior to visit with the physician. If a patient is identified as using tobacco, the type of tobacco used and amount of use will be recorded by RN or MA (ASKED). If identified as a current tobacco user, a note will be placed on their paperwork to indicate current tobacco use to their HATP physician. Current tobacco users will be ADVISED by HATP physician about the danger of smoking at every visit. Current tobacco users will be ASESSED for readiness to quit by HATP Physician at ever visit.If patient is not ready to quit at the time of assessment, this process ends.If patient is thinking of quitting within the next 6 months, a referral will be made to Social Work (SW) for further assessment and for assistance.Current tobacco users who are interested in quitting within the next 6 months will be seen by SW, if and when available, at their medical visit. All current tobacco users who are ready to quit will be assessed by SW for individual assistance. This could include any or all of the following:Nicotine replacement therapy (Nicotine patches, inhaler, gum, lozenges, nasal spray, etc.), prescribed by their HATP physician, according to the standards of care for smoking cessation;Prescription of Chantix, or Wellbutrin, prescribed by their HATP physician, according to the standards of care for smoking cessation;Referral to the State of Michigan “Quitline” via fax or by providing phone number to patient directly;Referral to the University of Michigan Health System’s tobacco cessation program.Referral to other community resources (Smoker’s Anonymous, other smoking cessation programs, etc.); and/orIndividual counseling by HATP SW.HATP SW will discuss follow-up with patients after assisting (ARRANGE). This can take place at a follow-up visit or phone call within 6 months from assistance.AIDS Service Organization Example: Wellness Services Inc.Purpose: Preventing and reducing tobacco use is essential to the sustainability of health care and to assist PLWH move along the HIV continuum of care. According to the US Dept. of Health and Human Services tobacco consumption causes cancers of the lung, esophagus, larynx, mouth, throat, kidney, bladder, pancreas, stomach, and cervix. Tobacco also causes acute myeloid leukemia, heart disease, stroke, aortic aneurysm, chronic obstructive pulmonary disease (COPD), asthma, hip fractures, and cataracts. With over 60% of PLWH using tobacco it is imperative that we reach our clients with reduction methods and assist with quit attempts. Policy: Wellness Services Inc. will use an evidence-based approach to identify and assist clients enrolled in comprehensive care services who use tobacco products. This includes support for clients who request assistance in their efforts to attain a smoke-free lifestyle. Dialogue with the clients regarding smoking cessation will be framed using the “5A’s Model” of Ask, Advise, Assess, Assist and Arrange. Key elements of the client support program include: All clients enrolled in Comprehensive Care Department services are continuously screened for tobacco use using the 5As model. All clients who self-identify as using tobacco products within the last six months are: Advised in a non-judgmental, respectful manner regarding the health benefits of smoking cessation Offer an internal referral for education on smoking cessation or strategies to manage nicotine withdrawal symptomsOffer a referral to the Quit Line Offer a referral to an ongoing community-based smoking cessation programs Procedure: For the client who requests assistance to reduce or quit smoking:Refer to Quit Line, give community resource list and refer to educational group Ensure that an assessment of the client's tobacco use history is completeProvide education and support on tobacco cessation by using the 5As modelProvide the client with client-friendly education materialsProvide information on pharmacotherapy options Work with client to receive pharmacotherapy prescriptionsIf the client does not want to quit smoking or to receive assistance to manage nicotine withdrawal symptoms:Provide the client with education as outlined in the “Assist” section on the Tobacco Use RecordReassure client that if they change their mind and would like assistance, they can inform a member of the healthcare team at any timeConduct 5As at 90 day intervals during monthly monitoring and at reassessment/assessment Carbon Monoxide Monitor PolicyA carbon monoxide (CO) monitor can be purchased as equipment or supplies for a Tobacco Use Reduction Program. The CO monitor can be used to record a baseline of client’s tobacco use, track progress, and as motivation for quitting tobacco products. For more information on ordering a CO monitor, visit . CO Monitor Policy Example: Mayo ClinicCarbon Monoxide Testing Procedure Purpose: This policy is intended to outline the procedures for the safe and appropriate use of Carbon Monoxide Testing in the Nicotine Dependence Center. Procedure 1. Training: All clinical staff will receive training in the health consequences of CO and in the proper use of the Carbon Monoxide Monitor. 2. Proper Use: a. Significance of Carbon Monoxide as a harmful byproduct of smoking tobacco is explained to the patient. b. Permission to test CO level is solicited. c. Procedure is explained or demonstrated to the patient and patient is asked if he or she has any questions. d. Test procedure i. Counselor will hand the CO monitor to the patient, as patient is able. ii. Patient is instructed to take deep breath. If patient is unable to hold breath for the full 15 seconds patient should hold for whatever length of time is comfortably tolerable. iii. After 15 seconds, patient will make seal with lips over the disposable mouthpiece and exhale. 3. Equipment Maintenance: a. All monitors should be registered with facilities as indicated by a barcode with an electronic product code (EPC) number. b. Calibration –Monitors will be calibrated at least every six months. c. Treatment program supervisor will assure that this is done and that documentation is maintained. 4. Safety/Infection Control: a. A new disposable cardboard mouthpiece is used for each person taking the test. They are designed for one use only. These mouthpieces fit into a connecting device (T-piece) to the CO monitor. Each patient should blow into the disposal cardboard mouthpiece which will be disposed of after testing. i. Disposal mouthpiece will be removed after the test using a germicidal disposable cloth. Both will be discarded. ii. The clinician has the discretion of wearing latex gloves during the CO testing. Gloves should be available in every clinical office.b. A T-piece on each CO Monitor is used to 'trap' a breath sample between two non-return valves. These valves also stop people 'sucking back' air through this T-piece. Each T-Piece should be replaced at least each month according to manufacturer guideline c. After each use the CO monitor should be wiped with a germicidal cloth.CAREWare Consent Form: Sample[INSERT AGENCY LETTERHEAD HERE]Consent for the collection and sharing of patient information to providers for persons who have HIV under the Tobacco Use Reduction Project____________________________ (Name of Agency) is mandated to collect certain personal information that is entered and saved in a database system called CAREWare. CAREWare records are maintained in an encrypted statewide database, in a secure server in Lansing. CAREWare aggregate reports will be used for documentation of tobacco dependence treatment services, and any client information used will be done so without revealing names or other information that would identify any specific client. The CAREWare database program allows for certain medical and support service information to be shared among providers who are funded for the Tobacco Use Reduction Project; this includes, but is not limited to: medical visits, lab results, demographic data, annual review information, and tobacco dependence treatment services. All providers who have access to the tobacco domain must sign confidentiality agreement forms and are committed to keeping client information secure. You have a right to opt out of this electronic sharing; however, you may be unable to receive some tobacco dependence treatment services. I______________________________ (Client Name) hereby provide my consent and authorization for ____________________________ (Name of Agency to enter my client specific information in the encrypted CAREWare database which is operated and maintained by MDHHS. ______________________________________________________Client signatureDate_______________________________________________________Witness SignatureDateResourcesThe following links and documents are resources that provide evidence, tools, or examples for a successful Tobacco Use Reduction Program. MDHHS TCS website hosts valuable information, videos, and presentations that can benefit providers tobaccoTobacco Dependence Treatment Medication Coverage for PLWHPlanOver-the-Counter NRT(gum, patch lozenge)Prescription(Chantix, Wellbutrin, inhaler, nasal spray)MedicaidCoveredNot eligible for MIDAPCoveredNot eligible for MIDAPMedicare Part DNot coveredMay be eligible for MIDAPCoverage varies by plan May be eligible for MIDAPDual EligiblePart D-no coverageMedicaid will coverNot eligible for MIDAPPart D -coverage varies by planMedicaid-no coverageNot eligible for MIDAPMichigan Drug Assistance Program (MIDAP)CoveredCoveredDefinitions:Medicaid- A state operated health care program that assists low-income families or individuals in paying for long term medical and custodial care costs. Medicare- A federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. Michigan Drug Assistance Program (MIDAP) - A state program that provides FDA approved HIV treatment drugs, and other medications, to people living with HIV who are low income. Eligibility varies greatly from Medicaid programs. Resources:Michigan Medicaid Health Plan Common Formulary: Part D Plan Finder: Tobacco Quitline: Drug Assistance Program: and Tobacco Specific ResourcesHIV Guide for Clinical Care, April 2014, Pgs. 189-196 Provider Smoking Cessation Handbook, produced by the Veterans Administration , July 2012HIV & Tobacco Use: Pharmacologic and Behavioral Methods to Help your Patients Quit, Mountain Plains AETC, March 2014 and Smoking Resources at video: Conversations with : video: Brian’s Story – Tips from a Former Smoker who is living with HIV - Resources for ProvidersTobacco Use and Dependence Treatment, 2009: Academy of Family Physicians “Ask and Act, Providers Tobacco Cessation Tool Kit: FDA approved tobacco cessation products: of Wisconsin Center for Tobacco Research & Intervention offers videos and other tobacco training materials at ctri.wisc.eduCDC Tips Campaign from former smokers: Free Toolkit for Community Health Facilities - the Future, Office of the Surgeon General video: Nicotine Dependency Screening Tool Resources for ClientsMichigan Tobacco QuitLine, 1-800-784-8660 or 1-800-QUITNOW, Smoking Cessation Handbook, Veterans Administration materials: . Public Health Service offers a free booklet, You Can Quit Smoking Now! Call 1-800-QUITNOW, tobaccoAmerican Cancer Society offers printed material and sponsors the Great American Smokeout on the third Thursday in November. Call 1-800-227-2345. American Heart Association offers printed material. Call 1-800-242-8721. American Lung Association offers quit smoking classes, printed material, cessation website. Call 1-800-586-4872. Telephone referral and cessation advice is available by calling 1-866-784-8937. National Cancer Institute offers a quit kit and telephone advice at 1-877-44U-QUIT. cancertopics/smokingNicotine Anonymous at 415-750-0328. nicotine-QuitNet Online Smoking Cessation, BecomeanEX: A website offering an online quit smoking program. ................
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